J.H.K.C. Psych. (1993) 3, 28-38

SPECIAL TOPIC: CHILD & ADOLESCENT PSYCHIATRY

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INTRODUCTION

The role of life events in the causation of psychiatric disorders was recognized long back by Adolf Meyer (1951) who suggested that even the most normal and essential events in life could contribute to psychiatric disorders. Literature concerning life events and stress in childhood is sparse in contrast to that in adults. In the last decade there have been few measures of stress in childhood (Compas, 1987; Johnson, 1986). Classical life events approach of Holmes & Rahe (1967) was used in Coddington's Social Readjustment Rating Scale (Coddington, 1972 a & b, 1984). Limitations of the life events checklist approach to study of stress in childhood have been discussed in various reviews (Goodyer, 1990 a & b, Rutter & Sandberg, 1992), mainly extrapolating from relevant literature on adults. However, Coddington's Social Readjustment Rating Scale or its modifications have been widely used in many studies (Monaghan, Robnison and Dodge 1979, Hurme 1981, Wertieb, Weigel and Feldstein 1987, Jensen et al, 1991). Till the alternative methodology of interview technique for assessing life stress is standardized and validated, studies using the checklists are likely to continue for some time.

Psychopathology in childhood has been found to be associated with many environmental factors and life events such as adverse family circumstances (Rutter, 1985 & 1989, Shaw and Emery, 1989, Goodyer, Wright & Altham, 1988), maternal separation or deprivation (Bowlby, 1969 & 1980, Rutter, 1981 & 1989, Wolkind and Rutter, 1985), birth of a sibling (Dunn & Kendrick, 1982, Dunn, 1988), parental diverce (Hetherington, 1988), bereavement (Van Eerdewegh et al, 1982), physical handicap (Wasserman & Allen, 1985), urbanism (Quinton, 1988), maternal depression (Mills et al, 1985). It has been found that these events assume etiological significance in a particular socio-cultural context. Brown & Harris (1989) emphasized that the significance of these events should be interpreted in the social context of its occurence. Another way of approaching this question of cultural relativity of stressful events can be via studying the same events in socio-culturally different populations and to examine and compare directions and strength of their relationships to psychopathology.

No studies have been reported from India on stress and psychiatric disorders in children and there is no assessment measure developed for Indian population. Only one study in India (Rangaseami & Kamakshi, 1983) on adolescent hysterics, used Coddington's Social Readjustment Rating Scale and reported that majority (85%) of hysterics had a significant life stress before the onset of symptoms.

Present study was planned to examine the relationship between stress and psychiatric disorders in children in India in a case-control study design. Being the first systematic study in this area, it was necessary to develop a measure of stress applicable to Indian population.

MATERIAL AND METHODS

LIFE EVENTS SCALE FOR INDIAN CHILDREN

British Life Event Inventory (Monoghan, Robinson & Dodge, 1979) which was an adaptation of Coddington's SRRS (Coddington, 1972) was adapted for use on Indian population. The process of adaptation involved evaluation of the British Inventory by experienced professionals in terms of relevance of items and appropriate stress score, keeping in mind the Indian socio-cultural context. Five items considered not relevant were deleted (e.g. becoming a full fledged member of a church, fathering an unwed pregnancy, pregnancy of unwed teenage sister), 15 new items were added (e.g. not being sent to school against child's wish, acquisition of television by family, physical punishment by parent, visit of relatives etc.), thus, making it a 50 item scale. Each event was assigned a stress score between 0-100 indicating stressfulness of the event. Test re-test reliability after 3 months (0.89) and interrater reliability (0.99) of stress scores were very high. Rank order correlation between assigned scores and actual scores of original British Life Event Inventory items and between random scores of the modified version of the inventory at three months interval was very high (i.e. 0.81 & 0.82 respectively). Final form of the scale has been called as Life Events Scale for Indian Children (LESIC), given as appendix, 1.

SAMPLE

The study was carried out on children attending the Child Psychiatry Clinic of the Dept. of Psychiatry at Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh during 1987-1989.

The city of Chandigarh has a total population of 0.64 million of which 0.58 million is urban; and overall literacy rate is 66% (census of India 1991). Children suffering from various psychiatric disorders of less than 12 months duration, other than organic brain disorders and mental retardation, diagnosed according to ICD-9 criteria were included. Detailed Clinical assessment was carried out to record the onset of symptoms (which should have been less than 12 months at the time of assessment), nature and severity of symptoms and its impact on the child. A consecutive sample of 80 children in 4-14 years age range and of both sexes fulfilling the above criteria was included in the study. A control group of normal children taken from the sibs of patients attending Pediatrics Outpatients, Dept. of PGlMER for minor physical ailments was selected. The control group was matched for the socio economic status, sex and age and represented the same socio-cultural and geographical region as the study group (X2 values not significant). These children were screened through Reporting Questionnaire for Children (RQC) by Giel et al (1981) to exclude any psychiatric disorders in them.

ASSESSMENT

Parents of these children, preferably mothers, who were all mentally healthy, were interviewed using LESIC. All the events listed in the Scale were asked whether these occured in the one year perior to the onset of psychiatric symptoms in the study group, or any time before that. Care was taken to include only those events which were independant of the psychiatric disorder in them. This was done by a detailed chronological history by a senior psychiatrist using his clinical judgement. In the control group, it was asked whether the event occured during one year prior to assessment or any time before that. The date, month and year of occurence of events was recorded as such. The period of recall in the study group was one to a maximum two years before assessment (i.e. one year prior to onset of symptoms of which maximum duration was 12 months) and one year in the control group. Total number of events (LE) and stress each child may have encountered was worked out. There were two time frames: (i) One year before onset of illness or before assessment and (ii) ever in life before that. Stress scores of each event which occured were summated to give an overall stress score (SS). In addition, information regarding the age, sex, education of the child and clinical diagnosis as applicable was recorded. Among the study group there were 27 cases of hysteria and emotional disorders, 12 of hyperkinesis and conduct disorders, 21 were diagnosed as special symptoms predominantly enuresis and 20 of miscellaneous categories (e.g. MOP deprssion, glue sniffing, specific developmental delay, migraine etc as per ICD-9 criteria).

RESULTS

Mean number of life events in the last one year was 6.1 ± 2.14 in the study group vs 5.43 ± 2.51 in the control group (t = 1.91, n.s.). However, the stress score was significantly higher in the study group (258.41 ± 98.10 vs 216.52 ± 112.22; t = 2.67, p < 0.01). Similar comparison for number of events prior to last one year (5.14 ± 2.47 vs 4.99 ± 2.58, t = 0.41, n.s.) and stress score (248.18 ± 114.43 vs 245.70 ± 133.67, t = 0.13, n.s.) did not show significant differences between the study and control groups.

Table 1 shows the comparisons of total number of LEs and total SS in different age categories in the two groups. As expected there was gradual and steady increase in the number of LE and SS in the normal popultaion. Similar trend was not seen in the study group where there was relatively higher number of LE and SS in the younger children (4-7 yrs) as compared to that in normals.

Data was analysed separately for two sexes and compared across two groups. Females scored significantly highr on LE (6.09 ± 2.20 vs 4.92 ± 1.97; t = 3.77, p < .01) and SS (254.69 ± 98.10 vs 197.96 ± 84.77; t = 4.38, p =< .01) in the study group as compared to normals. All other comparisons were insignificant.

Although the hyperkinetic and conduct disordered children scored higher on number of LE & SS in the last one year as compared to all other diagnostic categories, the difference was not statistically significant. However, when different diagnostic categories were compared with the Normal group (using Anova) most of the comparisons were significant for stress score in the last one year. Attempt was made to further analyse the stress experience within each diagnostic categories according to age and sex. The numbers in each category were small for any statistical analysis, however, trends revealed that younger children (4-7 yrs) suffering from neurotic and emotional disorders experienced greater stress in the last one year (LE mean 6.8 ± 3.32; SS mean 295.4 ± 99.10) as compared to older age (12-14 yrs) children (LE mean 5.0 ± 2.62; SS mean 217.0± 120.32). This trend was reversed in the diagnostic category of special symptoms where older children (12-14 yrs) scored higher on stress in the last one year (LE mean 9.67 ± 0.47, SS mean 422 ± 34.19) as compared to that in the younger (4-7yrs) children (LE mean 6.2 ± 2.22; SS mean 275 ± 89.98).

It was found that stress in the last one year had significant relationship with psychiatric disorders. Qualitative analysis of stress in the last one year was carried out.

The events were divided objectively into desirable (n = 7) undesirable (n = 35) and neutral (n = 8) through consensus by a group of professionals. Percentage frequencies for each of the events were calculated and difference in the two groups were worked out using Z test.

Life events items were further classified, depending upon the content, into six categories and those appearing with significantly greater frequency in the two groups were marked out as shown in table 3. The study group experienced 6 types of undesirable (mostly related to death, divorce and parental absence from home) and 2 types of desirable events with significantly greater frequency as compared to control group in whom only 4 types of undesirable events (mostly illness of sibs and parents), were found with greater frequency than those in the study group. In the study group events related to death, divorce or parent's absence from home were more frequently encountered.

DISCUSSIONS

This being the first systematic effort at studying life stress and psychiatric disorders in children in India, there were certain specific problems encountered. The first and the foremost was to choose a measure of stress applicable and relevant to Indian subjects. Considering the cultural variations in the situations considered stressful and linguistic aspects of the items (Brown & Harris, 1986, PP 163-165), othe life events inventeries developed in the West could not be directly applied to Indian population. Therefore, Indian adaptation of British Inventory was done retaining its basic concept and approach. "Holm's & Rahe's (1967) approach of assigning weighted stress scores to events has recently been criticised in research on adults, where personal meaning of events is considered a more important indicator of its stressfulness (Brown & Harris, 1986). There are not many studies on children on this aspect. Rende & Plomin (1991) reported that parents ratings of stress are significantly higher than child ratings for specific events and a composite stress measure.

This difference in children's perception of events being less stressful as compared to that of their parents might be a reflection of their cognitive immaturity due to which they are not able to fully appreciate its impact and consequences. Whether it is desirable to take children's perception or parent's perception in assessing stressfulness of events, is still an open question yet unresolved. In the present study, Holms & Rahe's approach was relied upon as a preliminary step till further experience with other methodologies, was gathered. The findings of this study revealed that disordered children experienced as many life events in the last one year as normal children but these were of more serious nature because the corresponding stress score was significantly higher in the sick group. This finding supports the view that the nature and seriousness of events is more relevant to occurence of psychiatric disorders rather than just the numbr of life events.

In the Life Events Scale for Indian Children (LESIC) assessment of stress was made on two time frame parameters i.e. last one year and ever in life prior to last one year. There is evidence in literature that life events during one year prior to onset of illness contribute directly to the occurence of psychiatric disorder or maladjustment (Brown & Harris 1978, Paykel 1978). On the other hand, keeping in mind the psychological approach of Adolf Meyer and the importance of total life stress experienced by the individual (Rutter 1986), the assessment of total life stress as well was undertaken in the present study. However, the findings revealed that the sick children did not differ from normal children in terms of their stress experience prior to last one year. It supports the point that more recent happenings are more relevant than the remote ones.

Age, Sex and Stress

Since the sample included a wide age range (4-14 yrs) it was necessary to consider the relationship between age and stress. It was expected that there should be a linear relationship between age of the child and the number of life events encountered and the stress score.

It was found that 4-7 years olds in the sick group experienced relatively higher number of LE and SS as compared to older children in the same group and same age children in the normal group (Table-I). There was significant increase in total number of LE and SS with increasing age in the normal group. However, in the sick group there was significantly higher number of LE and total SS in 4-7 years olds as compared to normal children of same age and their scores were similar to those of older children in the sick group. These findings indicate that although stress score was higher for children of all ages in the sick group, it was considerably higher for younger age children implying thereby that at younger age, stress has a greater role in the causation/precipitation of psychiatric disorder which decreased as children grew older. In other words it can be said that psychiatric disorders in younger age children were more related to extrinisic factors like stress.

Few studies related to age of the child and impact of life stress have pointed towards age specific vulnerabilities for specific events e.g. hospital admissions are most stressful to children between ages of 6 months and 4 years (Rutter 1989), and younger children are likely to react adversely to birth of a sib (Dunn et al 1981, Moore 1975). However, the present study points towards a more general vulnerability at younger age.

Girls in the sick group encountered more stress than boys in that group. The implications of this finding though interesting are more difficult to understand and interpret. Does it mean that psychiatric disorder in boys is not so much related to life stress experienced by them is a question that needs to be studied more intensively.

Stress and diagnosis

Number of life events and stress scores in the last one year and prior to one year were not found to be different access four diagnostic categories viz neurotic/conduct disorders, special symptoms, and miscellaneous. Children with hyperkinetic syndrome/ conduct disorder encountered maximum stress in the last one year as compared to all other diagnoses. Within each diagnostic group further analyses of age and stress revealed that among the neurotic and emotionally disturbed children there was maximum stress in 4-7 years olds. Among special symptoms group it was older children (12-14 yrs) who encountered maximum stress, and the children with hyperkinesis/ conduct disorder experienced uniformly high stress in the last one year across all ages. This data though small for statistical analyses and reliable conclusions, throws light on the possibility of relationship between stress and diagnosis.

Nature of stress and psychiatric disorder

Recent research on life events in adults has revealed that association of stress with psychiatric disorder is largely confined to unpleasant or undesirable events (Gerstein et al 1974, Paykel 1974, Andrew & Tennant 1978). Similar analysis carried out in the present study (Table 3) revealed that a significantly larger proportion of children with

32 psychiatric disorder experienced greater number of undesirable (6) as well as desirable (2) life events as compared to normal children. Among these, half of the undesirable events found in excess in the sick group related to death, divorce or parental absence from home (3 in number); others being serious physical illness of child (1), child abuse/physical punishment (1), and problems related to school (1).

On the other hand, undesirable events found in significantly larger proportion of normal children (4 in number) included illness of sibs/parents (3) and not being sent to school against child's wish (1). Obviously, these events are much less stressful than those reported in excess for disordered children. On the whole it was apparent that the psychiatric disorder in cildren was related more often to undesirable life events, in the last one year. This finding assumes greater significance particularly when viewed from the perspective of equal number of LEs encountered by the two groups of children in the last one year and supports the conclusion of other workers (Rutter 1981) that the effects of potentially stressful events does not depend largely on the number of such stresses encountered.

Limitations of the study

Limitations of the present study include the heterogenit of the study sample in terms of wide age range and multiple diagnostic categories; and control group was not taken from the general population. Other limitations of methodology of stress measurement needs attention in future research as mentioned in discussion.

CONCLUSION

This study highlights certain cross-cultural aspects of life stress research on children e.g. it was found that existing scales have limited applicability to other cultural settings like India where it was necessary to modify items. An objective assessment of stressfulness of events was preferred as the initial first step. It would be necessary to develop interview techniques for measuring stressf ulness of events, its personal meaning and impact in the given social context which would provide insights into the viscissitudes of life stress in varying socio-cultural backgrounds. The findings that it is the nature and quality of life events rather than its number which is more relevant in psychiatric disorders is in line with the reported literature. One additional finding which is of significance is that life stress contributes to psychiatric disorders more at a younger age than at older age.

It was also found that stressf ul events occuring in the preceding one year made a greater contribution to psychiatric disorder which is consistent with literature, However, in order to understand more fully the relationship between stress and psychiatric disorders in children, there is need to focus research on the mediational forces and mechanisms involved.

This study may be viewed as heralding the beginning of further research in this area in India.

Study Of Life Stress In Children With Psychiatric Disorders In India

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